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Why doctors must be advocates

The federal government recently announced the Chief Public Health Officer – the physician at the head of the Public Health Agency of Canada – should no longer set the agency’s own budget, leaving this task to a soon-to-be appointed administrator. While the risks and benefits of this approach continue to be debated, a widely cited column by the editor of a high-profile Canadian weekly magazine noted that public health should “stick to their needles”.

This sentiment is not new. Hon. Jason Kenney, during his tenure as the Citizenship and Immigration Minister, countered an op-ed calling for restoration of the Interim Federal Health program, penned by physicians, by arguing that doctors serve patients best when their focus is on disease treatment. You may ask, naturally: why should physicians advocate? Why should they be involved in shaping health policy?

As two trainees in the profession, we firmly believe our patients are why.

More than a century ago, Rudolf Virchow, a doctor considered as the father of modern pathology, famously stated: “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Our diseases, both in Virchow’s era and now, are as much a product of social arrangements – including housing, income, education and employment – as they are a consequence of biology.

As diseases become less and less infectious and more and more chronic, direct solutions such as John Snow taking the handle off the Broad Street pump to stop the spread of cholera in London will become increasingly rare. Medicine alone cannot stop the rising tide of obesity, the continued scourge of lung cancer or the persistent shadow of depression. From our experience with tobacco control, individual education or intervention is not enough to effect change. Only population-level policy and legislative changes, like banning smoking in public places or raising tobacco taxes, can produce lasting impact.

As trainees, we spend most of our time with our physician supervisors focused on individual patients – we are taught to diagnose, treat, communicate with and motivate our patients, and rightly so. When we advocate, it often takes place at the point of care – how to get an urgent MRI more quickly, or how to fight for access to an expensive medication. But when we take a step back, we realize that these are symptoms of a wider health and social system that needs improvement, and that our voices are needed more than ever. Indeed, we can become much more effective in our role when the economic and political powers also strive to keep people from becoming patients.

For example, during our pre-clinical training, we are taught to encourage exercise and healthy eating as first-line treatment in a variety of chronic conditions. As we progress to clinical rotations, however, we are increasingly confronted with questions beyond the individual level: how effective is prescribing exercise in practice when these motivated, hard-working patients are the same individuals who disproportionately live in our neighbourhoods that are not walkable? How meaningful is it to tell patients to consume healthy foods when we have “food deserts” in the very area they live? Physicians cannot stay outsiders to policy, because they bear witness to the resulting inequity in social determinants of health that drive patients to their offices each day.

Our compassion for patients drives our passionate advocacy efforts. Some have asked – and many will undoubtedly continue to ask – why advocacy is still relevant for physicians and trainees today; why we need to be involved in policy when increasing funder scrutiny, rising administrative burden, and exploding medical knowledge are more than enough to keep us busy. To them we humbly suggest the deep convictions with which we entered this profession: advancing equitable access is why. Promoting healthier community is why. Empowering vulnerable population is why. Our patients are why. Where we can join our voice with those in the shadows, there is nowhere else we would rather be.

Nina Nguyen is a third year medical student at Université de Sherbrooke. Follow Nina on Twitter @meimeian. Yan Xu is a third year medical student at Queen’s University. Follow Yan on Twitter @IMYanXu

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14 comments

Excellent–thanks for so beautifully expressing why the editorial in Maclean’s infuriated me (I hadn’t seen the item in the Globe & Mail, but see that it’s saying essentially the same things).

There’s little hope to seeing long-term change if public health “sticks to its needles” and physicians focus on individuals without looking at the bigger challenges they face in getting healthy or keeping themselves and their families healthy, like having access to decent and affordable housing and foods, getting a good education and jobs, addressing mental health issues, learning to be active, quitting smoking, learning how to be effective parents, and so on.

There is a lot of room for physicians, public health, community groups, and government to put their efforts together to achieve collective impact (the Tamarack Institute for Community Engagement is doing great work in this area). Both the Globe and Maclean’s editorials advocate for continuing the silos and priorities that offer limited chance of addressing the really important issues facing us.

Advocacy cannot happen without autonomy. Too many physicians are currently robbed of their autonomy, particularly in pathology, a field with myriad issues. The physicians who practice in that field are partly spineless but also silenced, for they are employees of large health systems rather than independent practitioners. This arrangement makes it risky if not career suicide for pathologists to advocate for patients if the advocacy is in conflict with the mission or budgets of their employers.

Hi Dr. Fullerton,
Thank you for your comment. The issue that we aimed to look at was not so much the policy decision of whether the Chief Public Health Officer should be able to set his own budget, which to my understanding there are opinions supporting both sides of the argument.

We instead focused on the accompanying contribution from the editor of Maclean’s suggesting that “public health should only stick to their needles”. We believe this is a narrow view of the ability of medical professionals to contribute to health policy through advocacy.

In the current era of patient-centred care, professional advocacy would ideally happen with patients. There are many examples that this is happening – Choosing Wisely Canada is a collaborative approach that has engaged the Canadian Medical Association, Patients Canada and Consumer Reports, and the National Seniors Strategy is jointly being pushed forward by the CMA and CARP.

Thanks. I did understand your position overall. However, when it comes to advocating, well-meaning MDs may be limited by their scope of knowledge.

If an MD does not understand the impact of debt and structural deficits or other factors external to medical care that may impact the ability for government to provide public services, can the MD truly represent the pstient’s best interests?

Can an MD who is now tasked with managing the health care system and rationing care, truly be a patient advocate?

While I agree that the physician perspective is important going forward, I see many self-professed physician advocates who simply demand more public resources. This is not advocacy.

Without fully understanding what it means to provide more and more public resources provincially or federally, many MDs appear to be ideologues and zealots rather than fully informed professionals who understand broader need for change.

You should re-read this excellent piece again. These students are advocating for physicians to work with other sectors to improve health, and therefore reduce the burden on healthcare. They’re not saying that advocacy involves asking for more resources; they are saying that advocacy means helping people to live healthier lives so that they don’t end up IN the healthcare system.

Certainly there are those MDs who simply demand additional public resources be diverted to healthcare; well-meaning or self-interested are questions that surround such “advocacy.”

But this is advocacy of a different level. It is MDs bringing their knowledge and understanding of disease trends and patterns they see, and then reaching out to other sectors to support their scope of knowledge in making changes to address the causes of these disease patterns. A totally different type of purposive action that is more true to the meaning of advocacy.

Good examples: demanding basic insurance coverage for refugees; working with public health, cities, communities and school boards to build healthier communities; advocating for calorie labelling and nutritional information around fast foods being sold. Here, they have a large part of the expertise and need to work with other sectors with other areas of expertise to make the healthy choice the right choice.

That’s all fine and well but all of what you describe costs MORE and Ontario has a debt of nearly 300 Billion with 10 B in annual interest costs. While MDs are busy advocating for more and more public health care they seem to forget that more public debt to provide them means FEWER services not more and more cuts to other areas that provide people with productive opportunity.

We have to look at the whole pie not just a piece .

MDs who believe they are advocating for patients to get the services the MD thinks gov’t should provide could be making getting them even more difficult. Public resources are finite.

It costs more but saves in the long run. If we can keep people healthy by changing the context they live in, we can reduce healthcare costs down the line. That’s the whole pie there, ma’am. That’s what we mean by reducing healthcare demand by increasing community health.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.